Trigger tools are algorithms that prompt clinicians to investigate a potential adverse event. These tools are in routine practice for detection of adverse drug events and have been used to identify diagnostic delays. Investigators randomized physicians to either no intervention or to receive triggers related to cancer diagnosis; each trigger was an abnormal diagnostic test result for which follow-up testing is recommended. Delays in acting on abnormal test results are a known cause of adverse events. Sending reminders to physicians based on the trigger process led to higher rates of recommended diagnostic evaluation completion and a shorter time to completion for two of the three studied conditions. These promising results suggest that trigger tools could play a role in improving diagnosis across a range of conditions.

Journal Article > Study

Diagnostic errors are a known threat to patient safety, and measuring their prevalence is challenging, particularly outside pathology and radiology settings. Past studies have highlighted classification systems and related prevention strategies, including the adoption of checklists. This study explored the use of a situational awareness (SA) framework to understand diagnostic errors in a primary care setting. Investigators interviewed providers involved in a diagnostic error and revealed that one level of SA was lacking (e.g., information perception, information comprehension, forecasting future events, and choosing appropriate action based on the first three levels). The authors found that applying the SA framework to analyze such errors provided deeper insight into the provider–work system interaction, which included important interface with the electronic health record. A past AHRQ WebM&M perspective and interview discussed diagnostic errors in medicine.